Patient Safety in the Operating Room

The right culture can result in the right outcomes and help avoid costly litigation

gaefold Patient safety in the operating room has long been a concern for hospitals. Numerous initiatives to improve OR care have had some impact, but problems persist. Wrong-site surgery, for example, has received a great deal of focus. The Joint Commission implemented a universal protocol in July 2004 that requires a preoperative verification process, the marking of the operative site and taking a “time-out” immediately before starting the procedure, among other things. But providers say that compliance is difficult and the number of reported incidents of wrong-site surgery has increased. Before the protocol went into effect, the Joint Commission received an average of five reported cases each month; after it was implemented, the number of cases reported nationally climbed to eight cases per month. The increase can be attributed to improved reporting, but the larger point is that wrong-site surgery continues to occur.

So what’s the problem? According to patient safety experts, one of the biggest barriers to improving patient safety in the OR is the culture. “Historically, the surgeon was in charge and no one questioned the surgeon,” notes David Feldman, M.D., vice president of perioperative services and vice chair of the department of surgery at Maimonides Medical Center in Brooklyn, N.Y. “But that’s the old way of doing business. The nature of medicine has changed, so the practice of medicine must change. Today, it’s imperative that everyone work together.”

Making that shift, however, is not easy. “Cooperation across disciplines falls apart at times. Surgeons see patient safety as a hospital issue, not a surgeon issue,” says Peter Angood, M.D., co-director and vice president and chief patient safety officer for the Joint Commission. For example, he says, “We hear anecdotally that a time-out before surgery is viewed as trivial and unimportant. That’s probably the most important part of the process.”

Adds Ruth Kilduff, managing principal, Integro Insurance Brokers, Boston, “During certain periods, such as hand-offs and shift change, there is increasing vulnerability when the culture is one of power and authority. The CEO needs to be sensitive to the cultural barriers so appropriate changes can be made.”

To overcome these problems, hospitals must first assess the culture of the OR, address top priorities and build teamwork among clinicians and supporting departments. “Everyone is important,” says Dean Griffen, M.D., immediate past-chair of the American College of Surgeons’ Patient Safety and Professional Liability Committee. “In the OR, the surgeon is often unapproachable. Everyone must understand that they are just one member of a team.”

This gatefold examines the risks associated with the OR and provides examples of how organizations can identify and address cultural issues.

Assessing Your OR Culture

As with other safety initiatives, understanding the culture of the operating room is crucial to success. A cultural assessment may be one of the best ways to measure OR quality and identify areas for improvement.

“The health care field is scared by poor science to support patient safety initiatives,” says Martin Makary, M.D., a surgeon and director of the Johns Hopkins Center for Surgical Outcomes Research. “Many efforts have no data to support whether or not they make a difference.” For example, Makary says that many of the key metrics used to measure quality and safety, such as mortality rates and infection rates, do not provide a true indication of the organization’s quality of care because they are influenced by the patient population. “Culture transcends these measures,” Makary says. “It influences care delivery.”

Makary and his colleagues developed a Safety Attitudes Questionnaire, adapted from the airline industry, to determine the staff’s outlook toward the work environment in the OR. “The questionnaire asks front-line providers how safe they feel their hospital is,” he says. “Their response is the best predictor of risk that hospitals have.” The SAQ is approximately 60 questions long and is intended to provide a cross-sectional look at the work environment, including the teamwork climate, the perception of management, job satisfaction, working conditions and safety. It can provide a benchmark with other organizations and help develop safety programs.

Makary recommends that the SAQ be conducted yearly. “If the culture doesn’t improve year-to-year, there’s a good chance that the improvement programs that are in place aren’t useful,” he says. The SAQ, he adds, is most effective when used as part of a comprehensive patient safety program that includes education and an internal review process.

Sample questions from the SAQ (OR version) include:

I would feel safe being treated here as a patient.
The administration of this hospital is doing a good job.
I am proud to work at this hospital.
I have seen others make mistakes that have the potential to harm patients.
Hospital management does not knowingly compromise the safety of patients.
Morale is high in the ORs here.
I am frequently unable to express disagreement with staff/attending physicians.
Important issues are well-communicated at shift changes.
High levels of workload are common in the ORs here.
I feel frustrated by my job.

Source: Sexton JB, & Thomas EJ. The Safety Climate Survey: Psychometric and Benchmarking Properties. Technical Report 03-03. The University of Texas Center of Excellence for Patient Safety Research and Practice (AHRQ grant #1PO1HS1154401 and U18HS1116401), 2006.

Assessing Interpersonal Communications in the OR

Another good predictor of OR culture is how OR staff perceive relations with their peers. ORs are high-stress environments and disruptive behavior, including angry outbursts, create difficult work environments. Disruptive behavior in the OR can lead to hostile work environments where caregivers are afraid to speak up for fear of reprisal, jeopardizing patient safety and the quality of care as a result.“Patient safety initiatives won’t work if people don’t communicate,” says Feldman of Maimonides. “You won’t get people to talk to each other if they don’t respect each other. Respect is like air. Without it, nothing else matters.”

Before embarking upon an initiative to improve communications in the OR, Feldman helped develop and administer a survey to gauge baseline impressions about conduct and behavior in the department. The initiative is now being adopted by other departments throughout the hospital. “Most staff work well together, but there are outliers,” Feldman says. The one-page Safety Climate Survey confirmed that the OR had behavioral issues that needed to be addressed. After research and consideration, the department selected and implemented the Crucial Conversations training program. The program, launched in January 2006, consisted of a one-hour monthly training session for one year. Since the OR has a weekly late day to allow for conferences and meetings, everyone was able to go through the program together. “The program teaches people how to talk to each other,” Feldman says. While that may seem basic, it’s a much-needed skill. “Everyone is more aware. A couple of individuals have become completely different people over the course of the year,” he says.

Safety Climate Survey

Code of Mutual Respect:	Ancillary & clerical staff and respectful behavior:	Nurses & technicians and respectful behavior:	Physicians and respectful behavior:
• I have a clear understanding of the code of mutual respect. • I believe the code of mutual respect will positively enhance our workplace and help us provide better care to our patients. • I believe physicians and staff are held to the same standards of professional behavior. • I think our leaders handle disrespectful behavior effectively. • When I see someone violating the code of mutual respect, I speak up. • Overall, I feel I am treated with respect by co-workers.	• Ancillary and clerical staff treat doctors with respect. • Ancillary and clerical staff treat nurses and technicians with respect. • Ancillary and clerical staff treat other ancillary and clerical staff with respect.	• Nurses and technicians treat doctors with respect. • Nurses and technicians treat other nurses and technicians with respect. • Nurses and technicians treat ancillary and clerical staff with respect.	• Doctors treat other doctors with respect. • Doctors treat nurses and technicians with respect. • Doctors treat ancillary and clerical staff with respect.

Source: Maimonides Medical Center, 2007

Top 5 Root Causes of Wrong-Site Surgery

Root-cause analysis of wrong-site surgeries reveals that breakdowns in communication remain the top cause for errors. However, failure to comply with procedure is a close second. The top five root causes of wrong-site surgery are all preventable; the challenge is changing culture and ensuring that proper protocols are met.

Wrong-Site Surgeries Reported by Year

The number of wrong-site surgeries increased steadily between 1995 and 2005, primarily because of increased reporting. Despite widespread recognition of the problem due in part to several high-profile cases and national prevention programs, incidents of wrong-site surgery still occur.

Breakdowns in Communication and the Impact on Liability

Communication breakdowns are a common reason for errors in the operating room, as well as during pre- and post-op care. Types of communication failures include the failure to listen to or solicit information from patients, families and other clinicians and the failure to convey information relevant to patient status or the course of care. The result can be significant harm or even death to a patient. For providers, breakdowns in communication may lead to an increased liability risk.

The American College of Surgeons released a study earlier this year that examines the impact of communication on patient safety and liability. A review of 460 closed claims against general surgeons found that 90 (19.6 percent) were attributable to failures in communication:

36 Claims stemmed from failure to communicate with patients and/or family members

19 Claims stemmed from communication failures with nurses

35 Claims resulted from communication failures with other physicians

The main reason for the breakdown in communication was a failure to spend enough time to accomplish ordinary tasks associated with the patient encounter, according to the study. For example, in many cases, the surgeon failed to ask for additional information about a patient’s status assuming that all was well. Or, the surgeon listened selectively, weighing in favor of the best-case scenario.

Disruptive Staff

Disruptive behavior is not uncommon in the operating room. In a survey of nurses, surgeons and anesthesiologists released last year by VHA Inc., 94 percent said that disruptive behavior needlessly contributes to adverse events and medical errors as well as negatively impacts the quality of care and can affect patient mortality.

Disruptive behavior was defined as any inappropriate behavior, confrontation or conflict such as sexual harassment, and physical and verbal abuse.

46% Respondents who said they knew of an event that occurred due to disruptive behavior.

19% Knew of an adverse event that occurred due to disruptive behavior.

22% Surgeons who who said they witnessed disruptive behaviorin other physicians on a weekly basis.

21% Nurses who have witnessed disruptive behavior in other nurses on a weekly basis.

Source: VHA, Inc., July 2006

Risk Managers Offer Their Viewpoints

Risk managers share their priorities and what they want administration to know about safety in the OR.

Teri Zimmerman
Risk counsel, Barberton (Ohio)
Citizens Hospital

“OR fire safety has been a collaborative effort between risk management and the director of the OR. We’ve worked with the department to implement time-outs, establish a protocol to prevent wrong-site survey, as well as monitor and intervene when inappropriate conduct [by physicians or staff] during surgical cases occurs. Another priority has been the creation of a nonpunitive culture. We’ve also created an OR Patient Safety Committee whose focus is solely on the risks intrinsic to the OR setting.”

Greg Terrell
Senior director of patient safety,
Tenet Healthcare Corp., Dallas

“I can’t overemphasize the importance of communication among all of the health care professionals within the OR suite, as well as others who have a stake in what goes on. This includes the blood bank, materials management, facility services and engineering. Each person has to have the ability or freedom to speak up when necessary without the fear of retaliation. It’s teamwork in the purest form.”

Douglas Borg
Director of insurance, Duke University Health System,
Durham, N.C.

“Safety in the OR has come a long way but there is still ample opportunity for improvement. Surgical and procedural time-outs have been proven to work, but we need to keep pushing. Patient identification in the OR and elsewhere within the hospital should continue to be a focus. The drive toward a culture of safety needs to continue.”

Peggy Martin
President and vice president–risk
management, Lifespan Risk Services, Providence, R.I.

“All members of the surgical team must participate in a preoperative huddle on every patient. Uncooperative physicians should be sanctioned in some way, preferably by their chief.”

Paul Smith
Vice president and general counsel, Cabell Huntington Hospital,
Huntington, W.Va.

“The CEO needs to get the message out to the physicians that time-outs and other procedures designed to prevent wrong-site surgery are serious and compliance is expected. Risk management and the OR staff are working to make the OR safer for patients, and anything that will encourage physicians to participate and comply is appreciated.”

How We Did It

This gatefold was produced by researching published studies and articles, and conducting interviews with hospital and industry executives.

Research: Lee Ann Runy lruny@healthforum.com

Design: Chuck Lazar clazar@healthforum.com

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